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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/issue/practitioners-agree-medication-reconciliation-value-frustration-and-difficulties-abound
August 09, 2023 - May 11, 2014
Communicating medication changes to community pharmacy post-discharge: the
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psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-acute-care-hospitals
October 23, 2019 - February 20, 2019
Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative
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psnet.ahrq.gov/issue/exploration-safety-climate-nursing-homes
January 03, 2017 - Study
An exploration of safety climate in nursing homes.
Citation Text:
Singer SJ, Kitch BT, Rao SR, et al. An exploration of safety climate in nursing homes. J Patient Saf. 2012;8(3):104-24.
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psnet.ahrq.gov/issue/hospital-ran-out-her-childs-cancer-drug-now-shes-fighting-end-shortages
February 06, 2019 - Newspaper/Magazine Article
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.
Citation Text:
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages. Noguchi Y. Health Shots and All Things Considered. National Public Ra…
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psnet.ahrq.gov/issue/pharmacist-supported-medication-review-training-general-practitioners-feasibility-and
July 29, 2020 - Study
Pharmacist-supported medication review training for general practitioners: feasibility and acceptability.
Citation Text:
Krska J, Gill D, Hansford D. Pharmacist-supported medication review training for general practitioners: feasibility and acceptability. Med Educ. 2006;40(12). d…
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psnet.ahrq.gov/issue/call-systems-thinking-approach-medication-adherence-stop-blaming-patient
November 09, 2022 - Commentary
A call for a systems-thinking approach to medication adherence: stop blaming the patient.
Citation Text:
Lauffenburger JC, Choudhry NK. A Call for a Systems-Thinking Approach to Medication Adherence: Stop Blaming the Patient. JAMA Intern Med. 2018;178(7):950-951. doi:10.1001/j…
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psnet.ahrq.gov/issue/criminal-liability-nursing-and-medical-harm
August 10, 2022 - Commentary
Criminal liability for nursing and medical harm.
Citation Text:
Maher V, Cwiek M. Criminal liability for nursing and medical harm. Hosp Top. 2024;102(2):117-124. doi:10.1080/00185868.2022.2101571.
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psnet.ahrq.gov/issue/tablet-splitting-common-yet-not-so-innocent-practice
August 31, 2022 - Study
Tablet-splitting: a common yet not so innocent practice.
Citation Text:
Verrue C, Mehuys E, Boussery K, et al. Tablet-splitting: a common yet not so innocent practice. J Adv Nurs. 2011;67(1):26-32. doi:10.1111/j.1365-2648.2010.05477.x.
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psnet.ahrq.gov/issue/comprehensive-perinatal-patient-safety-program-reduce-preventable-adverse-outcomes-and-costs
September 29, 2010 - Study
A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims.
Citation Text:
Simpson KR, Kortz CC, Knox E. A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims.…
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psnet.ahrq.gov/issue/making-doctors-better
June 15, 2016 - Commentary
Making doctors better.
Citation Text:
Gerada C, Chatfield C, Rimmer A, et al. Making doctors better. BMJ. 2018;363:k4147. doi:10.1136/bmj.k4147.
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psnet.ahrq.gov/issue/what-effectiveness-reporting-systems-promoting-learning-healthcare
September 23, 2020 - Review
What is the effectiveness of reporting systems in promoting learning in healthcare?
Citation Text:
Sehgal A. What is the effectiveness of reporting systems in promoting learning in healthcare? Br J Hosp Med (Lond). 2024;85(4):1-9. doi:10.12968/hmed.2023.0444.
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F…
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psnet.ahrq.gov/issue/why-do-interns-make-prescribing-errors-qualitative-study
December 16, 2009 - Study
Why do interns make prescribing errors? A qualitative study.
Citation Text:
Coombes ID, Stowasser DA, Coombes JA, et al. Why do interns make prescribing errors? A qualitative study. Med J Aust. 2008;188(2):89-94.
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psnet.ahrq.gov/issue/need-organizational-change-patient-safety-initiatives
May 12, 2010 - Study
The need for organizational change in patient safety initiatives.
Citation Text:
Anderson J, Ramanujam R, Hensel D, et al. The need for organizational change in patient safety initiatives. Int J Med Inform. 2006;75(12):809-17.
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psnet.ahrq.gov/issue/multicenter-multidisciplinary-high-alert-medication-collaborative-improve-patient-safety
December 04, 2016 - Study
A multicenter, multidisciplinary, high-alert medication collaborative to improve patient safety: the Singapore experience.
Citation Text:
Khoo AL, Teng M, Lim BP, et al. A multicenter, multidisciplinary, high-alert medication collaborative to improve patient safety: the Singapor…
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psnet.ahrq.gov/issue/electronic-prescribing-reduced-prescribing-errors-pediatric-renal-outpatient-clinic
July 08, 2008 - Study
Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic.
Citation Text:
Jani Y, Ghaleb M, Marks SD, et al. Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic. J Pediatr. 2008;152(2):214-8. doi:10.1016/j.jpeds.…
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psnet.ahrq.gov/issue/patient-safety-research-overview-global-evidence
September 29, 2017 - Review
Patient safety research: an overview of the global evidence.
Citation Text:
Jha AK, Prasopa-Plaizier N, Larizgoitia I, et al. Patient safety research: an overview of the global evidence. Qual Saf Health Care. 2010;19(1):42-7. doi:10.1136/qshc.2008.029165.
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Forma…
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psnet.ahrq.gov/issue/economics-medication-safety-improving-medication-safety-through-collective-real-time-learning
October 07, 2020 - Book/Report
Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning.
Citation Text:
Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. de Bienassis K, Esmail L, Lopert R, Klazinga N for the O…
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psnet.ahrq.gov/issue/advances-prevention-and-control-hais
August 20, 2018 - Book/Report
Advances in the Prevention and Control of HAIs.
Citation Text:
Advances in the Prevention and Control of HAIs. Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
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psnet.ahrq.gov/issue/oral-chemotherapy-safety-practices-us-cancer-centres-questionnaire-survey
July 23, 2014 - Study
Oral chemotherapy safety practices at US cancer centres: questionnaire survey.
Citation Text:
Weingart SN, Flug J, Brouillard D, et al. Oral chemotherapy safety practices at US cancer centres: questionnaire survey. BMJ. 2007;334(7590). doi:10.1136/bmj.39069.489757.55.
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